Examining Child Maltreatment Througha Neurodevelopmental Len.docx

Examining Child Maltreatment Through
a Neurodevelopmental Lens: Clinical
Applications of the Neurosequential
Model of Therapeutics
BRUCE D. PERRY
ChildTrauma Academy, Houston, Texas, USA and Department
of Psychiatry and Behavioral
Sciences, Northwestern University, Chicago, Illinois, USA
This article provides the theoretical rationale and overview of a
neurodevelopmentally-informed approach to therapeutic work
with maltreated and traumatized children and youth. Rather than
focusing on any specific therapeutic technique, the
Neurosequen-
tial Model of Therapeutics (NMT) allows identification of the
key
systems and areas in the brain which have been impacted by
adverse developmental experiences and helps target the
selection
and sequence of therapeutic, enrichment, and educational activ-
ities. In the preliminary applications of this approach in a
variety
of clinical settings, the outcomes have been positive. More in
depth
evaluation of this approach is warranted, and is underway.
Over the last 30 years, key findings in developmental
neurobiology
have informed and influenced practice in several clinical

disciplines, includ-
ing pediatrics, psychology, social work, and psychiatry. Despite
this influ-
ence, the capacity of these large clinical fields to incorporate
and translate
key neurobiological principles into practice, program, and
policy has been
inefficient and inconsistent. The purpose of this article is to
present prelimin-
ary efforts to integrate core concepts of neurodevelopment into
a practical
clinical approach with maltreated children. This neurosequential
model of
therapeutics (NMT) has been utilized in a variety of clinical
settings such
as therapeutic preschools, outpatient mental health clinics, and
residential
treatment centers with promising results (Perry, 2006; Barfield
et al., 2009).
Received 23 March 2009; accepted 28 April 2009.
Address correspondence to Bruce D. Perry, ChildTrauma
Academy, 800 Gessner, Suite
230, Houston, TX 77024, USA. E-mail: [email protected]
Journal of Loss and Trauma, 14:240–255, 2009
Copyright # Taylor & Francis Group, LLC
ISSN: 1532-5024 print=1532-5032 online
DOI: 10.1080/15325020903004350
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CONTEXT AND CURRENT STATUS
Development is a complex and dynamic process involving
billions of interac-
tions across multiple micro (e.g., the synapse) and macro
domains (e.g.,
maternal-child interactions). These interactions result in a
unique expression
of an individual’s genetic potential and create a miracle of
dynamic organiza-
tion in the trillions of component parts (e.g., neurons, glia,
synapses) compris-
ing the human brain. Maltreatment disrupts this hardy process;
trauma,
neglect, and related experiences of maltreatment such as
prenatal exposure
to drugs or alcohol and impaired early bonding all influence the
developing
brain. These adverse experiences interfere with normal patterns
of experi-
ence-guided neurodevelopment by creating extreme and
abnormal patterns

of neural and neurohormonal activity. The resulting negative
functional impact
of impaired or abusive caregiving on the developing child has
been well docu-
mented (e.g., Malinosky-Rummell & Hansen, 1993; Margolin &
Gordis, 2000).
As expected, in any brain-mediated function examined—from
speech tomotor
functioning to social, emotional, or behavioral regulation—
developmental
trauma andmaltreatment increase risk of dysfunction (see also
Perry & Pollard,
1998; Bremner & Vermetten, 2001; Perry, 2001, 2002; Anda et
al., 2006).
In the United States alone, there are millions of maltreated
children and
youth in the educational, mental health, child protective, and
juvenile justice
systems (Fitzpatrick & Boldizar, 1993; Graham-Berman &
Levendosky,
1998). The majority of these children do not receive adequate
mental health
services; indeed, most are not even known to be maltreated or
traumatized.
While current policy efforts to create trauma-informed practices
and programs
are a welcome start, for children and youth, focusing on trauma
alone is
insufficient. Practice, program, and policy must become
substance abuse,
attachment, and neglect informed as well; we must become fully
‘‘develop-
mentally informed’’ to understand and address the range of
problems related
to maltreatment. The following sampling of some principles of

neurodevelop-
ment illustrates the value of this broader view for clinical
practice.
PRINCIPLES OF NEURODEVELOPMENT
There aremanywell-documented and emerging findings
regarding the genetics,
epigenetics, and experience-determined elements of
neurodevelopment. Only a
few are listed below to serve as examples of how these facts and
concepts can
inform our understanding of maltreated children and therapeutic
work. More
complete reviews are available elsewhere (e.g., Perry, 2001,
2002, 2006, 2008).
Sequential Development
The brain is organized in a hierarchical fashion with four main
anatomically
distinct regions: brainstem, diencephalon, limbic system, and
cortex. During
Examining Child Maltreatment Through a Neurodevelopmental
Lens 241
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development the brain organizes itself from the bottom up, from
the least
(brainstem) to the most complex (limbic, cortical) areas. While
significantly
interconnected, each of these regions mediates distinct
functions, with the
lower, structurally simpler areas mediating basic regulatory
functions and the
highest, most complex structures (cortical) mediating the most
complex func-
tions. Each of these main regions develops, organizes, and
becomes fully func-
tional at different times during childhood. At birth, for example,
the brainstem
areas responsible for regulating cardiovascular and respiratory
functionmust be
intact for the infant to survive, and any malfunction is
immediately observable.
The neural networks involved, therefore, must be mostly
organized in utero in
order to become functional at birth. In contrast, the cortical
areas responsible for
abstract cognition have years before they will become fully
organized and
functional. Each brain area has its own timetable for
development. Micro-
neurodevelopmental processes such as synaptogenesis will be

most active in
different brain areas at different times and, thereby, be more
sensitive to
organizing or disruptive experiences during these times
(sensitive periods).
As the brain is developing from the bottom to the top, the
process is
influenced by a host of neurotransmitter, neurohormone, and
neuromodula-
tor signals. These signals help target cells migrate,
differentiate, sprout den-
dritic trees, and form synaptic connections. Some of the most
important of
these signals come from the monoamine neural systems (i.e.,
norepine-
phrine, dopamine, and serotonin). These crucial sets of widely
distributed
neural networks originate in the lower brain areas (brainstem
and dience-
phalon) and project to every other part of the developing brain.
This archi-
tecture allows these systems the unique capacity to
communicate across
multiple regions simultaneously and therefore provide an
organizing and
orchestrating role during development and later in life. Due to
their wide dis-
tribution throughout the brain, and their role in mediating and
modulating a
huge array of functions, impairment in the organization and
functioning of
these monoamine neurotransmitter systems can result in a
cascade of dys-
function from lower regions (where these system originate) up
to all of the

target areas higher in the brain. If the impairment occurs in
utero (e.g., pre-
natal exposure to drugs or alcohol) or in early childhood (e.g.,
emotional
neglect or trauma), this cascade of dysfunction can disrupt
normal develop-
ment. Simply put, the organization of higher parts of the brain
depends upon
input from the lower parts of the brain. If the patterns or
incoming neural
activity in these monoamine systems is regulated, synchronous,
patterned,
and of ‘‘normal’’ intensity, the higher areas will organize in
healthier ways;
if the patterns are extreme, dysregulated, and asynchronous, the
higher areas
will organize to reflect these abnormal patterns.
The clinical implications of this principle speak to the
importance of the
timing of developmental experience; the very same traumatic
experience will
impact an 18-month-old child differently than a 5-year-old.
Similar traumatic
experiences occurring at different times in the life of the same
child will
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influence the brain in different ways; in many cases, the
previous exposure
has sensitized the child, making him or her more vulnerable to
future events.
And so it is with the timing of positive experience; the
developmental stage
of a child has a profound impact on how an educational,
caregiving, or
therapeutic experience will influence the brain; somatosensory
nurturing,
for example, will more quickly and efficiently shape the
attachment neuro-
biology of the infant in comparison to the adolescent.
A more subtle clinical implication is that in order to most
efficiently
influence a higher function such as speech and language or
socioemotional
communication, the lower innervating neural networks (e.g.,
locus coeruleus
norepinephrine systems) must be intact and well regulated. An
overanxious,
impulsive, dysregulated child will have a difficult time
participating in, and
benefiting from, services targeting social skills, self-esteem,

and reading,
for example. The field of restorative neurology has for many
years empha-
sized the positive impact of repetitive motor activity in
cognitive recovery
from stroke. This principle suggests that therapeutic massage,
yoga, balan-
cing exercises, and music and movement, as well as similar
somatosensory
interventions that provide patterned, repetitive neural input to
the brainstem
and diencephalon monoamine neural networks, would be
organizing and
regulating input that would likely diminish anxiety, impulsivity,
and other
trauma-related symptoms that have their origins in
dysregulation of these
systems. Our preliminary findings, and those of others (B. van
der Kolk,
personal communication, June 2008) with maltreated children
with such
self-regulation problems, suggest that this is the case (Barfield
et al., 2009).
Activity-Dependent Organization: Use-Dependent Modification
The brain organizes in a use-dependent fashion. In the
developing brain,
undifferentiated neural systems are critically dependent upon
sets of environ-
mental and micro-environmental cues (e.g., neurotransmitters,
cellular adhe-
sion molecules, neurohormones, amino acids, ions) in order for
them to
appropriately organize from their undifferentiated, immature
forms (for

reviews, see Perry, 2001, 2008). The molecular cues that guide
development
are dependent, in part, upon the experiences of the developing
child. The
quantity, pattern of activity, and nature of the activation from
these neuro-
chemical and neurotrophic factors depend upon the presence and
the nature
of the total sensory experience of the child. When the child has
adverse
experiences—loss, threat, neglect, and injury—there can be
disruptions of
neurodevelopment leading to compromised functioning (see
below).
This principle has many clinical implications. Primary is the
role this
principle plays in psychopathology. Use-dependent changes in
the brain
are the origin of neuropsychiatric symptoms related to exposure
to threat,
fear, chaos, stress, and trauma. The monoamine systems
mentioned earlier
are crucial components of the stress-response neural networks
in the brain.
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When a child (or an adult) is threatened and activates this stress
response in
an extremely prolonged or repetitive fashion, the neural
networks involved
in this adaptive response will undergo a ‘‘use-dependent’’
alteration. The
very molecular characteristics of individual neurons, synaptic
distributions,
dendritic trees, and a host of other microstructural and
microchemical
aspects of these important neural networks will change. And the
end effect
is an alteration in the baseline activity and reactivity of the
stress response
systems in the traumatized individual. The brain will ‘‘reset’’—
acting as if
the individual is under persistent threat. The details of this
process have been
well described elsewhere (Perry & Pollard, 1998; Perry, 2001).
The principle of use dependence is at the heart of effective
therapy.
Therapy seeks to change the brain. Any efforts to change the
brain or systems
in the brain must provide experiences that can create patterned,

repetitive
activation in the neural systems that mediate the
function=dysfunction that
is the target of therapy. In many cases, this will mean (as
mentioned above)
that the target of the intervention should be the innervating
neural systems
and not the area or system that is the final mediator of the
function=
dysfunction (e.g., physical exercise helps stroke victims recover
speech).
This is a significant problem in the conventional mental health
approach to
maltreated children; many of their problems are related to
disorganized or
poorly regulated networks (e.g., the monoamines) originating
lower in the
brain. Yet, our clinical interventions often provide experiences
that primarily
target the innervated cortical or limbic (i.e., cognitive and
relational
interactions) regions in the brain and not the innervating source
of the dys-
regulation (lower stress-response networks). Even when
targeting the appro-
priate systems in the brain, we rarely provide the repetitions
necessary to
modify organized neural networks; 1 hour of therapy a week is
insufficient
to alter the accumulated impact of years of chaos, threat, loss,
and humilia-
tion. Inadequate ‘‘targeting’’ of our therapeutic activities to
brain areas
that are not the source of the symptoms and insufficient
‘‘repetitions’’ com-
bine to make conventional mental health services for maltreated

children
ineffective.
The origins of—and therapeutic recovery from—neglect are
manifesta-
tions of the principle of use dependence as well. Neglect, from a
neurodeve-
lopmental perspective, is the absence of the necessary timing,
frequency,
pattern, and nature of experience (and the patterns of neural
activation
caused by these experiences) required to express the genetic
potential of a
core capability (e.g., self-regulation, speech and language,
capacity for
healthy relational interactions). Neglect-related disruptions of
experience-
dependent neural signals during early life lead to a range of
abnormalities
or deficits in function (see Perry, 2001, 2006). As discussed
above, the
malleability of the brain shifts during development, and
therefore the timing
and specific ‘‘pattern’’ of neglect influence the final functional
outcome. A
child deprived of consistent, attentive, and attuned nurturing for
the first 3
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years of life who is then adopted and begins to receive
attention, love, and
nurturing may not be capable of benefiting from these
experiences with the
same malleability as an infant. In some cases, this later love is
insufficient to
overcome the dysfunctional organization of the neural systems
mediating
socioemotional interactions. With little appreciation of
neurodevelopment,
neglect-related problems in maltreated children are missed (in
over 80% of
children under the age of 6 removed by child protective
services, there are
significant developmental problems, yet this population rarely
receives a
developmental assessment in most states), ignored (a minority
of children
in child protective service care with mental health, learning,
speech and
language, or developmental problems receive consistent
services), or
lumped into the overinclusive current label of ‘‘complex’’
trauma or, worse,

bipolar disorder. Even when children do receive mental health
services,
neglect-related issues are rarely appreciated as having a distinct
pathophy-
siology and pathogenesis related to but different from trauma.
Disproportional Valence of Early Childhood Experience
The sequential development of the brain and the activity
dependence of
neurodevelopment create times during development when a
given neural
system is more sensitive to experience than others. In healthy
development,
that sensitivity allows the brain to rapidly and efficiently
organize in response
to the unique demands of a given environment to express from
its broad
genetic potential those characteristics that best fit the child’s
world; different
genes can be expressed, and different neural networks can be
organized
from the child’s potential to best fit that family, culture, and
environment.
We all are aware of how rapidly young children can learn
language, develop
new behaviors, and master new tasks. The very same
neurodevelopmental
sensitivity that allows amazing developmental advances in
response to
predictable, nurturing, repetitive, and enriching experiences
makes the
developing child vulnerable to adverse experiences.
The simple and unavoidable conclusion of these
neurodevelopmental

principles is that the organizing, sensitive brain of an infant or
young child
is more malleable to experience than a mature brain. While
experience
may alter the behavior of an adult, experience literally provides
the organiz-
ing framework for an infant and child. Because the brain is most
plastic
(receptive to environmental input) in early childhood, the child
is most vul-
nerable to variance of experience during this time. Again, the
clinical, prac-
tice, and policy implications are profound. Early identification
and aggressive
early interventions are more effective than reactive services.
Despite solid
research documentation on early intervention and effective
therapeutic
services targeting young mothers, infant mental health, home
visitation
programs, and high-quality child care programs, support for
these programs
is scant and inadequate.
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Relational Mediation of Major Developmental Experiences
Life is full of novelty, unpredictability, challenges, stressors,
and, often,
trauma. There are individual differences in how we cope with
and overcome
stress and trauma. Much is yet to be understood; genetic factors,
for example,
appear to influence hardiness or sensitivity. Yet, one recurring
observation
about resilience and coping with trauma is the power of healthy
relationships
to protect from and heal following stress, distress, and trauma.
This relational
modulation of stress is mediated by two interrelated and broadly
distributed
systems in the human brain: the stress response systems and
neural networks
involved in bonding, attachment, social communication, and
affiliation. To
best understand the intimate interdependence of these systems
in the brain,
it is useful to examine the conditions into which the human
brain evolved.
For the vast majority of the last 200,000 years, humans have
lived in

hunter-gatherer clans in the natural world. The size of our living
groups
was small—40 to 60 people. These multigenerational,
multifamily groups
were the main source of safety from the dangers of the world.
Our survival
depended upon the ability to communicate, bond, share, and
receive from
other members of our family and clan. Without others, the
individual could
not survive in the natural world. Then, and today, the presence
of familiar
people projecting the social-emotional cues of acceptance,
compassion,
caring, and safety calms the stress response of the individual:
‘‘You are one
of us, you are welcome, you are safe.’’ This powerful positive
effect of
healthy relational interactions on the individual—mediated by
the relational
and stress-response neural systems—is at the core of
relationally based
protective mechanisms that help us survive and thrive following
trauma
and loss. Individuals who have few positive relational
interactions (e.g., a
child without a healthy family=clan) during or after trauma have
a much
more difficult time decreasing the trauma-induced activation of
the stress
response systems and therefore will be much more likely to
have ongoing
symptoms (i.e., there will be more prolonged and intense
activation of
the stress response systems and, hence, a ‘‘use-dependent’’
alteration in these

systems). This capacity to benefit from relational interactions
is, in turn,
derived from our individual developmental experiences.
At birth, the developing stress-response networks in the brain
(including
the monoamine systems mentioned above) are rapidly
organizing. The
primary source of the patterned somatosensory interactions that
provide
the organizing neural input to the developing stress-response
system is the
primary caregiver. The role of the stress response system is to
sense distress
(e.g., hunger, thirst, cold, threat) and then act to address this
challenge to
homeostasis to promote survival: if hungry, eat; if cold, find
shelter; if thirsty,
drink. Infants are incapable of meeting their needs; they cannot
feed, warm,
or comfort themselves and depend upon their caregiver to
become the exter-
nal stress regulator. The primary caregiver, through consistent,
nurturing, and
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predictable responsive caregiving, provides the patterned,
repetitive neural
stimulation (again, the principle of ‘‘use dependence’’) for the
infant’s devel-
oping brain required to build in an adaptive and flexible stress-
response
capacity (self-regulation) as well as healthy attachment
capabilities. If the
caregiver is depressed, stressed, high, inconsistent, or absent,
these two cru-
cial neural networks (stress-response and relational) develop
abnormally.
The result is a child more vulnerable to future stressors and less
capable of
benefiting from the healthy nurturing relational supports that
might help
buffer future stressors or trauma.
Early developmental experiences with caregivers—the infant’s
first
exposure to humans—create a set of associations and
‘‘templates’’ for the
child’s brain about what humans are. Are humans safe,
predictable? Are
they a source of sustenance, comfort, and pleasure? Or are they
unpredict-
able and a source of fear, chaos, pain, and loss? These initial

caregiving
experiences create the ‘‘template’’ that the child carries into
future relational
interactions, either increasing or decreasing the capacity of the
child to ben-
efit from future nurturing, caring, and invested adults.
Relationships in early
childhood, then, can alter the vulnerability=resilience balance
for an indivi-
dual child (do human relational interactions calm you when
distressed
because your ‘‘template’’ is based upon nurturing, or do they
make you feel
more anxious and vulnerable because your primary caregiver
was inconsis-
tent and abusive?).
There is another aspect of the interconnectedness of the stress
response
and relational neurobiology. The human experience is
characterized by
clan-on-clan, human-on-human competition for limited
resources. Indeed,
the major predator of humans is now, and has always been,
other humans.
In our competitive, violent past, encounters with unfamiliar,
nonclan mem-
bers were as likely to result in harm as in harmony. As the
infant becomes
a toddler and the toddler becomes a child, the brain is making a
catalogue
of ‘‘safe and familiar’’ attributes of the humans in his clan; the
language,
the dress, the nonverbal elements of communication, and the
skin color of
his family and clan become the attributes of ‘‘safe and

familiar’’ that, in future
interactions with others, will tell his stress response networks to
be calm. In
contrast, when this person interacts with strangers, the stress
response sys-
tems activate; the more unfamiliar the attributes of this new
person, the more
the activation. In some cases, a clan’s beliefs may have
exacerbated this; if the
child grows up with ethnic, racial, or religious beliefs and
values that degrade
or dehumanize others, the stress activation that results in an
encounter with
different people can be extreme. In this case, relational
interactions activate
and exacerbate trauma-related stress reactivity. A recent study
by Chiao and
colleagues (2008), for example, showed that fear-related social
cues from
individuals from one’s own group=ethnicity have greater
‘‘power.’’ They will
induce greater amygdala activation than similar cues from
individuals not in
one’s group. Similar group contagion of positive emotional
states has been
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documented (e.g., Fowler & Christakis, 2008). All of this points
to the power-
ful influence of the social milieu on individual neurobiological
functioning.
The social milieu, then, becomes a major mediator of individual
stress
response baseline and reactivity; nonverbal signals of safety or
threat from
members of one’s ‘‘clan’’ modulate one’s stress response. The
bottom line
is that healthy relational interactions with safe and familiar
individuals can
buffer and heal trauma-related problems, while the ongoing
process of ‘‘tri-
balism’’—creating an ‘‘us’’ and ‘‘them’’—is a powerful but
destructive aspect
of the human condition, exacerbating trauma in individuals,
families, and
communities attempting to heal.
The clinical implications of this understanding of the power of
relational
health are, again, profound. As one would predict, research
suggests that

social connectedness is a protective factor against many forms
of child mal-
treatment, including physical abuse, neglect, and nonorganic
failure to thrive,
as well as a means of promoting prosocial behavior (Belsky et
al., 2005;
Caliso & Milner, 1992; Egeland, Jacobvitz, & Sroufe, 1988;
Rak & Patterson,
1996; Travis & Combs-Orme, 2007; Chan, 1994; Coohey, 1996;
Guadin
et al., 1993; Hashima & Amato, 1994; Pascoe & Earp, 1984;
Altemeier,
O’Connor, Sherrod, & Vietze, 1985; Benoit, Zeanah, & Barton,
1989; Crnic,
Greenberg, Robinson, & Ragozin, 1984; Gorman, Leifer, &
Grossman, 1993).
The number, quality, and stability of relational interactions
matter to the
child. Removing children from abusive homes also may remove
them from
their familiar and safe social network in school, church, and
community.
And worse, the presence of new and unfamiliar individuals can
actually acti-
vate the already sensitized stress-response systems in these
children, making
them more symptomatic and less capable of benefiting from our
efforts to
comfort and heal. Our well-intended interventions often result
in relational
impermanence for the child: foster home to foster home, new
schools,
new case workers, new therapists as if these are interchangeable
parts. They
are not. Even ‘‘best-practice’’ therapeutic work is ineffective in
an environ-

ment of relational instability and chronic transition.
TRANSLATIONAL NEUROSCIENCE: THE
NEUROSEQUENTIAL
MODEL OF THERAPEUTICS
Over the last 20 years, we have been adapting our clinical
practice to incor-
porate emerging findings from neuroscience. This has resulted
in a shift from
a traditional medical model approach to a more developmentally
sensitive,
neurobiology-guided practice. The results are promising (see
Perry, 2006;
Barfield et al., 2009). A brief overview follows.
The neurosequential model of therapeutics (NMT) is not a
specific
therapeutic technique or intervention; it is an approach to
clinical work
that is informed by neuroscience (Perry, 2006). It is, in short,
an effort in
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translational neuroscience that has been evolving over the last
15 years. The
NMT process structures assessment and identification of
primary problems
and strengths, and it sequences the application of interventions
(educational,
enrichment, and therapeutic) in a way that reflects the child’s
specific devel-
opmental needs in a variety of key domains and is sensitive the
to core
principles of neurodevelopment—some of which have been
articulated
above. There are three central elements of the model: a
developmental
history, a current assessment of functioning, and a set of
recommendations
for intervention and enrichment that arise from the process.
NMT Developmental History
The brain organizes as a reflection of experiences both good
and bad. To
understand an individual, therefore, one needs to know his or
her history.
The NMT assessment is focused on the developmental history of
the child.
The NMT core assessment reviews the timing, nature, and
severity of devel-
opmental challenges; these are scored, resulting in an estimate

of develop-
mental ‘‘load.’’ This also allows an estimate of which neural
networks and
functions would plausibly be impacted by the child’s
developmental insults
or history of trauma (Perry, 2001, 2006). For example,
intrauterine insults
such as alcohol use or perinatal caregiving disruptions (such as
an impaired,
inattentive primary caregiver) will predictably alter the
norepinephrine, ser-
otonin, and dopamine systems of the brainstem and
diencephalon that are
rapidly organizing during these times in life. These early life
disruptions, in
turn, will result in a cascade of regulatory functions impacting a
wide distri-
bution of other brain areas and functions that these important
neural systems
innervate (for more, see Perry, 2008).
A second important element of the NMT core assessment is a
review of the
relational history of the child during development. As discussed
above, rela-
tional milieu can be protective and confer some capacity to
buffer the impact
of trauma, while relational instability and multiple transitions
can exacerbate
developmental insults. This NMT relational health history
provides important
insights into attachment and related resiliency or vulnerability
factors that
may have impacted the functional development of the child (see
Figure 1).

NMT Functional Status and Brain ‘‘Mapping’’
The second component of the NMT process is a review of
current functioning
that allows us to make estimates of which neural systems and
brain areas are
involved in the various neuropsychiatric symptoms. An
interdisciplinary staff-
ing is typically the method for this functional review. This
process helps in
the development of a working functional brain map for the
individual (see
Figure 2). This visual representation gives a quick impression
of develop-
mental status in various domains of functioning: A 10-year-old
child, for
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example, may have the speech and language capability of an 8-
year-old, the
social skills of a 5-year-old, and the self-regulation skills of a
2-year old. This
visual ‘‘map’’ is very helpful when talking about trauma, brain
development,
and the rationale of various recommendations with educators,
mental health
staff, caregivers, and clients. It is also very useful to help track
progress;
improvement, as shown in changes in the shadings of various
brain areas,
is quick to see in the comparison of today’s brain map with one
from
6 months ago and is a powerful reinforcement for tired parents
and hard-
working frontline staff who feel their efforts are for naught.
This review requires a working knowledge of neural
organization and
functioning. In order to ‘‘localize’’ a set of functions to any set
of brain net-
works or regions, the senior clinician leading the
interdisciplinary NMT staff-
ing must know child development, clinical traumatology, and
developmental
FIGURE 1 Relationship between developmental insults (trauma
and neglect) and functional
organization of the brain. Using the NMT developmental history
measure (higher scores indicate
more developmental insult such as trauma and neglect) and the
NMT functional brain mapping
scores (higher scores indicate positive functioning), a linear

relationship is seen between num-
ber and intensity of developmental insults and the compromise
in normal development and
functioning of the brain. It is of interest to note that individuals
who fall below the line tend
to have more profound relational poverty (e.g., multiple
placements, disengaged or unhealthy
primary caregiving) during development, and those above the
line have relatively more protec-
tive relational health (e.g., extended family, few placement
disruptions, more stable family rela-
tionships). The individuals at upper left (NMT FS!
approximately 90–100) are healthy
comparison children. The outlying individual at lower left is a
child with autism, healthy caregiv-
ing, and minimal adverse experiences during development.
(Bruce D. Perry # 2008)
250 B. D. Perry
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neurosciences. At present, this is the major impediment in
exporting the NMT
approach: It requires a senior clinician to lead the process with
a unique
combination of clinical and preclinical skills.
NMT Interventions
The third major element of the NMT process is providing
specific recommenda-
tions. The NMT ‘‘mapping’’ process helps determine a unique
sequence of
developmentally appropriate interventions and enrichments that
can help the
child reapproximate a more normal developmental trajectory. As
outlined in
brief below, these recommendations are made with various
principles of neu-
robiology in mind; while many deficits may be present, the
sequence in which
these are addressed is important. The more the therapeutic
process can repli-
cate the normal sequential process of development, the more
effective the
FIGURE 2 NMT functional brain ‘‘map’’: 6-year-old
traumatized and neglected child vs. com-
parison child (normal development). This map is generated from
an interdisciplinary staffing
process examining the functional status of various brain-
mediated functions. Each rectangle in
the diagram indicates a brain function. Each rectangle is shaded
to indicate functional status
(see key above). Brain functions (e.g., regulation of heart rate:

Brainstem; speech and lan-
guage: CTX; attunement: Limbic) are ‘‘localized’’ to a brain
region mediating the specific func-
tion (this oversimplification attempts to assign function to the
brain region that is the final
common mediator of the function with the knowledge that
almost all brain functions are influ-
enced and mediated by complex, trans-regional neural
networks). This approximation allows
a useful estimate of the developmental=functional status of the
child’s key functions, estab-
lishes the ‘‘strengths and vulnerabilities’’ of the child, and
determines the starting point and
nature of enrichment or therapeutic activities most likely to
meet the child’s specific needs.
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interventions are (see Perry, 2006). Simply stated, the idea is to
start with the
lowest (in the brain) undeveloped=abnormally functioning set of
problems
and move sequentially up the brain as improvements are seen.
This may
involve initially focusing on a poorly organized
brainstem=diencephalon and
the related self-regulation, attention, arousal, and impulsivity
by using any
variety of patterned, repetitive somatosensory activities (which
provide these
brain areas with the patterned neural activation necessary for
reorganization)
such as music, movement, yoga (breathing), and drumming or
therapeutic
massage. Once there is improvement in self-regulation, the
therapeutic work
can move to more relational-related problems (limbic) using
more traditional
play or arts therapies; ultimately, once fundamental dyadic
relational skills
have improved, the therapeutic techniques can be more verbal
and insight
oriented (cortical) using any variety of cognitive-behavioral or
psychodynamic
approach. Further, the recommendations and enrichments are
not limited to the
conventional limits of ‘‘mental health’’ symptoms; issues in
speech, learning,
motor functioning, and social functioning are all addressed as
part of a compre-
hensive, more holistic approach to the child and her or his
family.

Patterned, repetitive activities shape the brain in patterned
ways, while
chaotic experiences create chaotic dysfunctional organization.
Therapeutic
activities, then, are most effective when implemented with
focused repetition
targeting the neural systems one wishes to modify. One cannot
change a
neural system without activating it; one cannot learn how to
write by
watching a DVD on how to write—one has to hold the pencil,
make the move-
ments, and practice and master the skill. The NMT assessment
and functional
mapping allow targeted therapeutic efforts in the neural systems
that mediate
the child’s specific symptom array. When symptoms related to
the persisting
‘‘fear’’ response (common in maltreated children) are
addressed, therefore,
remembering that these first arise in the brainstem and then
move through
the brain up to the cortex, the first step in therapeutic work is
brainstem
regulation. The child may also have a host of cortically
mediated symptoms
such as self-esteem problems, guilt, and shame. The most
effective interven-
tion process would be to first address and improve self-
regulation, anxiety,
and impulsivity before these cognitive problems become the
focus of therapy.
A key component of the NMT recommendations relates to the
child’s
current relational milieu. A primary finding of our clinical work

(and many
other researchers; see above) is that the relational environment
of the child
is the major mediator of therapeutic experiences. Children with
relational sta-
bility and multiple positive, healthy adults invested in their
lives improve;
children with multiple transitions, chaotic and unpredictable
family relation-
ships, and relational poverty do not improve even when
provided with the
best ‘‘evidence-based’’ therapies. A simple metric, the NMT
relational health
index, scores the number and quality of relational supports
capable of
providing the safe, nurturing, and attuned environment in which
the
recommended therapeutic, educational, and enrichment
activities are to be
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provided. In many cases, these children’s caregivers or parents
have similar
developmental traumas, loss, or neglect; we can generate a
similar ‘‘map’’ for
the key members of the child’s relational network with the goal
of identify-
ing the strengths and vulnerabilities of the adults who will be
involved in
helping the child. Recommendations for co-therapeutic
activities where
parent and child can engage and receive mutually beneficial
services are
common. In some cases, the specific interventions required to
help the child
are obvious, but the relational environment is so chaotic, and so
relationally
impoverished or impermanent (e.g., foster care), that the
recommended
interventions are impossible and the ultimate outcomes poor.
FUTURE DIRECTIONS
Awareness of key principles of neuroscience and
neurodevelopment can
improve practice, programs, and policy in child maltreatment. A
key chal-
lenge is translating the emerging concepts into practical
improvements in
our clinical systems and in our therapeutic approach. A first and
very impor-
tant step is increasing capacity. Not enough parents, teachers,
therapists,

judges, or physicians know enough about child development or
the basics
of brain organization and function. Simply increasing awareness
of the key
principles of development and brain function would, over time,
lead to inno-
vations and improved outcomes; oddly enough, even though
neurodevelop-
mental principles impact all child-related disciplines, we rarely
teach the core
concepts and facts of neurodevelopment to our trainees in
education, social
work, medicine, law, pediatrics, psychology, and psychiatry.
An additional step is to continue to develop and study the
impact of
interventions that begin to incorporate some of the plausible
clinical implica-
tions of these principles (e.g., massage, yoga, EMDR, music and
movement).
While funding for research in ‘‘alternative’’ interventions is
difficult to obtain,
federal and philanthropic funders should be educated about the
neurobiolo-
gical plausibility of some seemingly ‘‘fringe’’ interventions and
encouraged to
fund clinical trials; if these interventions are proven to be
effective, they
could be included in conventional mental health reimbursement
models.
While in its ‘‘infancy,’’ we believe that the NMT, as well as
other neuro-
biologically informed, developmentally sensitive clinical
approaches, offers
much promise. We continue to learn and remain hopeful that

this approach
will help us better understand and heal maltreated children.
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(2006). The enduring effects of childhood abuse and related
experiences: A

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Barfield, S., Gaskill, R., Dobson, C., & Perry, B. D. (2009).
Implementing the neuro-
sequential model of therapeutics (NMT) with filial therapy in a
therapeutic pre-
school setting: Implications for work with children with serious
emotional
disturbance. Manuscript submitted for publication.
Belsky, J., Jaffee, S. R., Sligo, J., Woodward, L., & Silva, P. A.
(2005). Intergenerational
transmission of warm-sensitive-stimulating parenting: A
prospective study of
mothers and fathers of 3 year olds. Child Development, 76,
384–396.
Benoit, D., Zeanah, C. H., & Barton, M. (1989). Maternal
attachment disturbances
and failure to thrive. Infant Mental Health Journal, 10, 185–202.
Bremner, J. D., & Vermetten, E. (2001). Stress and
development: Behavioral and bio-
logical consequences. Development and Psychopathology, 13,
473–489.
Caliso, J. A., & Milner, J. S. (1992). Childhood history of abuse
and child abuse
screening. Child Abuse and Neglect, 16, 647–659.
Chan, Y. (1994). Parenting stress and social support of mothers
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their children in Hong Kong. Child Abuse and Neglect, 18, 261–

269.
Chiao, J. Y., Iidaka, T., Gordon, H. L., Nogawa, J., Bar, M.,
Aminoff, E., et al. (2008).
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Coohey, C. (1996). Child maltreatment: Testing the social
isolation hypothesis. Child
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Crnic, K., Greenberg, N., Robinson, N., & Ragozin, A. (1984).
Maternal stress and
social supports: Effects on the mother-infant relationship from
birth to eigheen
months. American Journal of Orhospychiatry, 52, 550–557.
Egeland, B., Jacobvitz, D., & Sroufe, L. A. (1988). Breaking the
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Fitzpatrick, K. M., & Boldizar, J. P. (1993). The prevalence and
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Fowler, J. H., & Christakis, N. A. (2008). Dynamic spread of
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Gaudin, J., Polansky, N., Kilpatrick, N., & Shilton, P. (1993).
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Perry, B. D. (2001). The neuroarcheology of childhood
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developmental costs of adverse childhood events. In K. Franey,
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(Eds.), Textbook
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service, research, and education in child maltreatment and
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Due Jan 15 by 10:59pm Points 50 Submitting a text entry
box or a file upload
Attempts 0 Allowed Attempts 2
Start Assignment
(https://waldenu.instructure.com/courses/24309/modules/items/6
10646)
Many individuals face challenges in career decision-making due
to sociocultural factors that limit or otherwise
negatively influence their ability to make self-directed career
choices. Discrimination, economic constraints, and

social supports are just a few of these factors that are
highlighted in this Week’s Learning Resources,. In this
assignment, you will build on your discussion post considering
how these and other factors might influence the
career development of your future clients or students, focusing
on your role in addressing these factors.
To Prepare for Activity
Review this Week’s discussion posts about the factors that
might influence the the career development or
access to decent work for marginalized groups.
Research the Walden Library for peer-reviewed articles about
how to address factors that influence career
development of marginalized populations.
Read through the template that is located in the Learning
Resources for this assignment.
REFLECTION PAPER: WORKING WITH
MARGINALIZED COMMUNITIES
RESOURCES
Be sure to review the Learning Resources before completing
this activity.
Click the weekly resources link to access the resources.
WEEKLY RESOURCES
(https://waldenu.instructure.com/courses/24309/modules/items/6
10648)
BY DAY 7
https://waldenu.instructure.com/courses/24309/modules/items/6
10646
https://waldenu.instructure.com/courses/24309/modules/items/6

10648
COUN_6753_Week7_Assignment_Rubric
Develop an advocacy statement that addresses the importance of
diversity and advocacy as it relates to career
counseling. When creating your advocacy statement, be sure to
address the key components of advocacy,
including a discussion of how you might advocate for clients
and students across micro, meso, and macro levels
of society. Much like a theoretical orientation statement, your
goal is to describe your commitment to social
change and advocacy for all clients and students in a fair and
safe manner.
Note: Your advocacy statement should be one to two paragraphs
in length. A meaningful statement requires
more than a simple sentence stating your beliefs or aspirations.
Your advocacy statement should be a tool to
begin dialogue between you and your clients/students to explain
the ways you work in your role as a
counselor to address the needs of clients/students who may be
marginalized on the basis of some aspect of
their social identity.
Describe how your clients or students might be challenged by
various sociocultural factors on their career
development. Then, in 2-3 pages,
Describe three culturally sensitive ways in which you might
apply career development theories while also
addressing these socioculural factors.
Include specific advocacy strategies to address the
client’s/student’s needs at the appropriate levels.

You must cite at least 2 peer-reviewed articles to justify how
you are addressing the sociocultural factors and the
specific advocacy strategies you selected.
Before submitting your final assignment, you can check your
draft for authenticity. To check your draft,
access the Turnitin Drafts from the Start Here area.
1. To submit your completed assignment, save your Assignment
as COUN6753+WK7Assgn+last
name+first initial.
2. Then, click on Start Assignment near the top of the page.
3. Next, click on Upload File and select Submit Assignment for
review.
SUBMISSION INFORMATION
Criteria Ratings Pts
25 pts Adherence to
Assignment
Expectations:
•Develop an
advocacy
statement that
addresses the
importance of
diversity and
advocacy as it
relates to career
counseling *
Address the key
components of

advocacy,
including how to
advocate for
clients and
students across
micro, meso,
and macro
levels of society
* Describe
commitment to
social change
and advocacy
for all clients
and students in
a fair and safe
manner * One to
two paragraphs
in length
•Describe how
clients or
students might
be challenged
by various
sociocultural
factors on their
career
development.
Then, in 2-3
pages,
•Describe three
culturally
sensitive ways
to apply career
development
theories while

25 to >22.4 pts
A
Thoroughly addresses all
required components of the
assignment with a well-
developed, cohesive, and
insightful narrative that
exceeds expectations.
22.4 to >19.9 pts
B
Thoroughly addresses
all required
components of the
assignment with a
well-developed
narrative.
19.9 to >17.4 pts
C
Addresses some
of the required
components.
17.4 to >0 pts
F
Addresses few
to no required
components.

Total Points: 50
Criteria Ratings Pts
12.5 pts
12.5 pts
addressing
these factors
•Include specific
advocacy
strategies to
address the
client’s/student’s
needs at the
appropriate
levels •Cite at
least 2 peer-
reviewed
articles to justify
strategies
Assimilation &
Synthesis of
Ideas:Course
content is
synthesized and
supported with
information from
the learning
resources and
examples.
12.5 to >11.24 pts
A

Critically evaluates
course content and
main points.
Supports the
evaluation with
information from the
learning resources
and
personal/professional
experiences.
11.24 to >9.99 pts
B
Synthesizes the
course content to
illustrate main points
and supports the
synthesis with
information from the
learning resources
and
experiences.
9.99 to >8.74 pts
C
Identifies key points
from the course
content and supports
the key points with
minimal information
from the learning
resources or

experiences.
8.74 to >0 pts
F
Key points are
missing and minimal
to no information
from the learning
resources or
experiences is used.
Expression and
Formatting: The
extent to which
the submission
demonstrated
writing quality.
12.5 to >11.24 pts
A
Writing is organized,
concise, and scholarly
written with no
grammatical errors.
11.24 to >9.99 pts
B
Writing is organized,
concise, and scholarly
written with minimal to no
grammatical errors.

9.99 to >8.74 pts
C
Writing is unclear
or interrupted by
grammatical
errors.
8.74 to >0 pts
F
Writing lacks
clarity,
organization and
has significant
grammatical
errors.

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